Criminal abortion — the abortion with the consent of the woman executed in the way and in terms for which criminal liability is provided. Complications of illegal aborting can be shown by weakness, dizziness, consciousness violations, mucopurulent and bloody vaginal allocations, pain in the bottom of a stomach, a hyperthermia, the accruing intoxication and polyorgan insufficiency. Criminal abortion is diagnosed by means of vaginal survey in mirrors, a bimanualny palpation, ultrasonography of bodies of a small pelvis. For treatment of complications use antibiotics, haemo statics, infusional therapy, a wide range of operational methods.
About criminal (illegal, illegal, criminal) abortion it is when the gestation is interrupted by the woman independently or in her consent by the person without the corresponding medical education. As a rule, such intervention is carried out out of medical institutions. Abortion is considered criminal also at its carrying out by the obstetrician-gynecologist outside a specialized institution or without medical or social indications after the 12th week of gestational term. According to experts of Institute of Guttmakher (USA) studying problems of abortions in the world about 20 million pregnancies annually illegally are interrupted, as a result of complications nearly 70 thousand women perish. The highest rates are recorded in developing countries. In Russia criminal abortions make 3% of all cases of aborting, more than a half of them are presented by interruption of teenage pregnancy.
Reasons of criminal abortion
Use by women of illegal ways of interruption of a gestation is caused by social factors: educational and cultural level, belonging to a certain social group, relation of society to undesirable pregnancies, features of legal regulation. Are the most common causes of illegal abortions:
- Desire to hide pregnancy. An attempt to interrupt a gestation out of walls of medical institution is made more often by teenagers who for performance of medical abortion need the consent of parents. Fear of publicity — a significant factor for the women who made adultery or belonging to social group where the intolerant relation to illegitimate conception practices.
- The missed opportunity to make abortion. In Russia late interruption of a gestation (from 12 to 22 week) is allowed in the presence of certain indications — medical (HIV, tuberculosis and other serious illness) or social (the death of the husband, more than 3 children, divorce). After 22 weeks term the fruit is considered the living person therefore abortion can be equated to murder.
- Ban on performing abortions. In a number of the states the decision on abortion is limited by law or it is considered unacceptable from the religious point of view. At impossibility to get rid of the unwanted child in time "abortion round" to the adjacent countries, women try to interrupt a gestation independently or with someone's help.
- Illiteracy. In certain cases pregnant women, being afraid of consequences of official abortion, decide on application of the "sparing" abortive techniques — thermal, physical impacts, reception of hormonal medicines or uterotonichesky means. Efficiency of such ways is extremely low, toxic impacts on the woman and a fruit are possible.
The mechanism of aborting depends on a way of performance of criminal abortion. Reception of various medicines (steroid antiprogestagenny means, synthetic analogs of female sex hormones, uterotonichesky medicines) assumes death of a germ, violation of processes of implantation, the strengthened reduction of uterine muscles with exile of a fruit. Introduction to the tservikalny channel and a cavity of a uterus of chemicals, various objects is directed to stimulation of an abortion due to damage of fetal egg. Criminal interruption of a gestation at which use special medical tools, provides office of a fruit with its covers from a uterine wall.
At extra hospital introduction to a vagina and a uterus of chemical reagents, parts of plants, various objects and even special tools requirements of an asepsis and antiseptics usually are not observed. As a result significantly the risk of a microbic obsemeneniye of mucous increases. The situation is aggravated during the traumatizing a wall of body, a congestion in the uterine cavity of clots of blood and the destroyed remains of fetal egg which are good nutrient medium for development of pathogenic microorganisms. Endometrium, and then other covers of a uterus, appendages, a pelvic peritoneum at first is involved in infectious and inflammatory process. In the absence of adequate medical care generalization of an infection with development of peritonitis and sepsis is possible.
At systematization of forms of criminal interruption of the occurred pregnancy consider a set of factors, from terms of performing abortion to the used methods and means. Such approach allows to consider as much as possible possible medical risks and to develop the optimum scheme of assistance to the patient. Experts in the sphere of obstetrics and gynecology distinguish the following options of criminal abortions:
- On carrying out terms: early and late illegal abortions. Usually the later the woman decides to get rid of the child, the complications and the remote consequences are more serious. Besides, aborting in the presence of a viable fruit can be regarded as murder and to aggravate criminal responsibility.
- In the place of termination of pregnancy: the abortions executed in house conditions and unspecialized medical institutions. Though interruption of a gestation is considered criminal in either case, its carrying out outside medical institution increases probability of a failure and differs in more serious consequences.
- On the performer of abortion: independent termination of pregnancy by the woman, the aborting executed not by the physician, the non-core expert, the obstetrician-gynecologist out of specialized institution or without the corresponding indications. Complications are probable in all cases, however the abortions which are carried out by nonspecialists are most dangerous.
- On a way of aborting: medicamentous, mechanical, "national" methods. For medicamentous abortions hormonal medicines and uterotonik use. At mechanical the kateterization of a uterine cavity with filling of chemical reagents, vacuum aspiration, a curettage, introduction of sharp objects, physical impacts is possible (blows in a stomach, heavy lifting). "National" methods assume drink of broths, mustard bathtubs, etc.
- On character of complications: with bleeding, infection, poisoning, an embolism. Gemorragiya are a consequence of a delay of parts of fetal egg, a trauma, a koagulopatiya. The infected abortions happen uncomplicated feverish (to localization of an infection in a uterus), complicated feverish (to distribution of an inflammation to a small pelvis), septic.
Symptoms of criminal abortion
Clinical manifestations of a pathological state depend on the chosen way of illegal intervention. At reception of the hormonal means and medicines stimulating reduction a miometriya poisoning with nausea, vomiting, dizziness, a headache is possible. In hard cases of overdose of toxic substances (quinine, an ergot) raises or sharply pressure falls, heartbeat becomes frequent, the woman feels interruptions in work of heart, the oglushennost, confusion or loss of consciousness is noted. At some patients against the background of medicamentous abortion plentiful ongoing uterine bleeding develops.
At mechanical ways of criminal interruption of a gestation the massive uterine bleedings with bystry deterioration in the general health and indicators of haemo dynamics revealed at 25-40% of women who transferred illegal abortion are most often observed. Accession of an infection is demonstrated by the accruing hyperthermia, the amplifying pains in nadlobkovy area, mucopurulent vaginal allocations. Usually the condition of the patient is considerably broken: there is a weakness, bystry fatigue, pallor, perspiration, dizziness. At an embolism of a pulmonary artery there is sharp thorax pain, short wind, heartbeat, fear of death.
World Health Organization abortions, especially criminal, are recognized as the most serious problem of protection of female reproductive health in many states. From 13 to 60% of a maternal lethality in the different countries are caused by complications after illegal interruption of a gestation. In 80% of cases sepsis, in 14% — bleeding, in 6% — peritonitis is a cause of death of the patient after criminal abortion. At mechanical and chemical interventions ruptures of a vagina and neck of a uterus, a perforation of a uterine wall, an urethra, bladder, rectum, loops of a large and small intestine, chemical burns of mucous membranes, the DVS-syndrome are possible. Against the background of bleeding and inflammatory processes (a sharp endometritis, a salpingit, an adneksit) infectious and toxic shock, a renal liver failure can develop.
As the gestation not always successfully is interrupted by a criminal way, the fruit which underwent toxic influences can have malformations. The remote consequences of the complicated illegal abortions are chronic endometritises, adneksita, endotservitsita, colpitises, an erosion of a neck, violation of a menstrual cycle. Often reproductive function suffers – the risk of habitual not incubation of pregnancy, an extra-uterine gestation, premature birth, fetoplatsentarny insufficiency, anomalies of patrimonial activity, an increment of a placenta and other obstetric complications considerably increases. To 40-80% of the women who transferred criminal abortion remain fruitless. At some patients the stressful postabortion syndrome with a depression, suicide thoughts, sense of guilt, sexual frustration, the use of psychoactive agents develops.
Problems of diagnostic search at criminal abortions are establishment of the fact of termination of pregnancy, objective assessment of a condition of reproductive organs and completeness of exile of a fruit, identification of possible damages. Even if the patient does not report about illegal abortion, careful inspection allows to reveal its signs. Inspection usually includes such methods as:
- Survey on a chair. At a vaginal research increase in the uterus having a softish consistence is noted. At a vagina there can be blood clots. Often allocations from a neck are found. At a bimanualny palpation morbidity in the lower part of a stomach is defined. The hematoma after perforation is presented by volume education in the field of appendages, infiltration of the vaginal arches is characteristic of a parametritis.
- Ultrasonography of pelvic bodies. During ultrasonic inspection in a uterus fetal egg or its parts can be revealed. Expansion of a uterine cavity at the expense of a blood congestion is possible. For more exact visualization transabdominal ultrasonography is recommended to be added with a transvaginal research. The method also allows to estimate thickness and a condition of a uterine wall, distribution of inflammatory process on other bodies.
To women with probable criminal interruption of a gestation appoint the general blood test in which decrease in quantity of erythrocytes, , increase in SOE, and also the general analysis of urine often is defined. Experts estimate characteristics of a hemostasis (fibrinogen, a prothrombin, AChTV), investigate biochemical indicators of blood (the ALT, NUCLEAR HEATING PLANT levels, the general protein, glucose, the general bilirubin, urea, creatinine), carry out the ECG. At reasonable suspicion on ekstragenitalny complications carry out ultrasonography of abdominal organs, a X-ray analysis of lungs, KT of bodies of a thorax. Illegal abortion is differentiated with threat of interruption of a gestation, ektopichesky pregnancy, an acute appendicitis, a puzyrny drift, a placentary polyp. According to indications appoint consultations of the infectiologist, the urologist, the surgeon, the nephrologist, the hematologist, an angiokhirurg.
Treatment of criminal abortion
At illegal termination of pregnancy the patient is subject to the emergency hospitalization. The purpose of actions of the doctor is elimination of the arisen complications, therapeutic actions are carried out taking into account protocols of treatment of uterine and intra belly bleedings, inflammatory diseases of reproductive organs, septic states, peritonitis, embolism. Conservative therapy of complications of criminal aborting assumes appointment of the following groups of medicines:
- Antibiotics. Antibacterial therapy is directed to fight against activators of infectious and inflammatory processes. Selection of medicines is whenever possible carried out taking into account sensitivity of microorganisms. Parenteral ways of introduction of medicines in combination with prevention of dysbacteriosis are preferable.
- Haemo statics. Styptic medicines are shown at the proceeding gemorragiya connected with violation of the curtailing system of blood. Are applied both locally, and it is system. The coagulants influencing different links of system of a hemostasis increase coagulability of blood and allow to stop bleeding.
- Infusion solutions. Use of colloidal and kristalloidny structures provides restoration of volume of the circulating blood and its rheological characteristics, food and a bystry detoxication of an organism that is especially important at medicamentous poisonings. In especially serious consequences of abortion carry out haemo sorption, a hemodialysis.
Intensive symptomatic therapy with purpose of cardiotonic medicines, gepatoprotektor, diuretics, antioxidants, antiagregant and other medicines is directed to correction of the polyorgan violations characteristic of criminal termination of pregnancy. At inefficiency of conservative treatment of the patient carrying out operation is recommended.
The volume of surgical interventions is defined by the revealed pathology. The Nekrotizirovanny remains of endometrium, a fruit and its covers are evacuated from a uterine cavity by means of a curettage or vacuum aspiration, high-quality audit of a uterus is provided. In the presence of tuboovarialny inflammatory educations the tubektomiya, a tubovarektomiya is carried out. Depending on a damage rate of body and existence of infectious complications the ushivaniye of a punched opening or a hysterectomy is recommended to patients with perforation of a uterine wall. Identification of signs of a pelvioperitonit and the poured peritonitis is the basis for laparoscopic or laparotomichesky intervention with sanitation, audit, drainage of an abdominal cavity, and often and removal of a uterus with appendages. In difficult cases the resection of an epiploon, intestines is carried out, the intestinal stoma, a tsistostoma is removed.
Forecast and prevention
The later the woman with the complications caused by criminal abortion asks for medical care, the forecast is worse. Emergence of heavy frustration and death of the patient are most probable at mechanical options of interruption of a gestation with penetration into a uterus cavity. Preventive actions assume active promotion of contraception from a school bench, informing women from risk groups about dangers of criminal interventions, legislative regulation of questions of a child-bearing taking into account interests of the woman, ensuring the available obstetric and gynecologic help to patients with undesirable pregnancy.